Permit C ITY OF TI GARD SEWER CONNECTION PERMIT
A ll DEVELOPMENT SERVICES PERMIT #: SWR2005 -00294
. .� ' 13125 SW Hall Blvd., Tigard, OR 9 7223 503 - 639 -4171 DATE ISSUED: 9/19/2005
PARCEL: 1 S 134BC -00300
SITE ADDRESS: 12280 SW SCHOLLS FERRY RD ZONING: C -
SUBDIVISION: GREENWAY TOWN CENTER LOT: JURISDICTION: TIG
Project Description: 0.3 edu increase. •
TENANT NAME:
CWS NO: FIXTURE UNITS:
CLASS OF WORK: ALT DWELLING UNITS: 0.3
TYPE OF USE: COM NO. OF BUILDINGS:
INSTALL TYPE: BUSWR IMPERV SURFACE:
Owner: FEES
VINNACOMBE CONSULTING Description Date Amount
12790 SE BLUFF RD
SANDY, OR 97055 [SWUSA] Sewer Connection Fee 9/19/2005 $780.00
Total $780.00
Phone: 503 826 - 1726
Contractor:
REQUIRED ITEMS AND REPORTS
Phone:
Reg #:
This Applicant agrees to comply with all the rules and regulations of the Clean Water Services. The permit expires 180
days from the date issued. The total amount paid will be forfeited if the permit expires. The Agency does not guarantee
the accuracy of the side sewer laterals. If the sewer is not located at the measurement given, the installer shall prospect
3 feet in all directions from the distance given. If not so located, the installer shall p rchase a "Tap and Side Sewer"
Permit and the Agency will install a lateral. ATTENTION: Oregon law requires yo to follow rules adopted by the
Oregon Utility Notification Center. Those rules are set forth in OAR 952 - 001 -001 thr gh PAR 952 - 001 -0100. You
may obtain copies of these rules or direct questions to OUNC by calling 503 -246 69 r 1- 800 -33 -2344.
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Issued by: , P, , } 2 Permittee Signature: l l
Call 503 - 639 -4175 by 7:00 a.m. for an inspection tha • - Mess day.
This permit card shall be kept in a conspicuous place on the job site , til completion o the project.
Approved plans are required on the job site at the time • each inspection.
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Accumulative Sewer Tally Parcel # 1 S,13;46C 00300„ _ _ ,
Tenant,Name: Oregon, Community Credit Union This SWRt2005`'00294 _ ' , • '
Site Address: "12280 SW Scholls` Ferry Rd . : This PLM #.2005 -00466 , . .
o
Fixture Value Previous Previous Credits Capped Fixture Fixture New New
# value capped off value added added total total
count off #s count # value #s values
Baptisery/Font 4 „ . .. 0 0 - 0 0 0
Bath - Tub /Shower 4 0 .. ' 0 0 0 0
- Jacuzzi/Whirlpool 4 0 0 0 0 0
Car Wash - Each Stall 6 . , , 0 0 0 0 0
- Drive through 16 - 0 - . 0 0 0 0
Cuspidor/Water Aspirator 1 0 0 0 0 0
Dishwasher- Commercial 4 0 0 0 0 0
- Domestic 2 : ` -. 0 1:: 2 1 2
Drinking Fountain 1 0 . ;: 0 0 0 0
Eye Wash 1 0 0 .. 0 0 0
Floor Drain /Sink - 2 inch 2 0 .- 0 0 0 0
- 3 inch 5 0 ' 0 0 0 0
- 4 inch 6 0 0 0 0 0
- Car Wash Drn 6 - . 0 , - 0 0 0 0
Garbage Disposal
- Domestic (to 3/4 HP) 16 0 0 0 0 0
- Commercial (to 5 HP) 32 •. 0 0 0 0 0
- Industrial (over 5 HP) 42 0 0 0 0 0
Ice Machine /Refrigerator Drain 1 0 0 0 0 0
Oil Sep (Gas Station) 6 0 = , 0 - , 0 0 0
Rec. Vehicle Dump station 16 , ; = ';i 0 0 0 0 0
Shower - Gang (per head) 1 ., ; 0 0 . ~ 0 0 0
- Stall 2 0 0 ;` 0 0 . 0
Sink - Bar /Lavatory 2 0 0 .� e- 0 0 0
- Bradley 5 0 r: 0 ,: ::`,.:, 0 0 0
- Commercial 3 0 0 1` 3 1 3
- Service 3 0 -, 0 0 0 0
Swimming Pool Filter 1 ' . 0 0 0 0 0
Washer - Clothes 6 ; - .,N . 0 0 0 0 0
Water Extractor 6 s. 0 0 0 0 0
Water Closet - Toilet 6 0 0 0 0 0
Urinal 6 ti 0 _” , 0 0 0 0
.
Previous EDU Count ' >'., 0 0 ... 0
Capped EDU Credit .. '...- -. 0
TOTALS 0 0 0 0 2 5 2 5
Current Fixture Value 5 divided by 16 = 0.3 Current EDU 1 EDU = $ 2,600
Previous Fixture Value 0 divided by 16 = 0.0 Previous EDU
Change 5 divided by 16 = 0.3 over (under) $ 780.00
Enter EDU Change Here'. 0.3
Notes:
Authorized Name /Signature:.Dodie Rossetti - Date: I '
Building Division
Note: The property owner shall retain the ORIGINAL sewer tally record. If credits exist, this document will serve as a voucher
which must be submitted to the City of Tigard Building Division to redeem credits towards future system development charges.
i:\Building\Sewer Tally \SewerTallySheet.xls 7/1/05
Accumulative Sewer Tally Parcel # 1S134BC -00300
Tenant Name: Oregon Community Credit Union This SWRf N/A
Site Address: 12280 SW Scholls Ferry Rd This PLM# 2005 -00466 CREDITS
Fixture Value Previous Previous Credits Capped Fixture Fixture New New
# value capped off value added added total total
count off #s count # value #s values
Baptisery/Font 4 0 0 0 0 0
Bath - Tub /Shower 4 0 0 0 0 0
- Jacuzzi/Whirlpool 4 0 0 0 0 0
Car Wash - Each Stall 6 0 0 0 0 0
- Drive through 16 0 0 0 0 0
Cuspidor/Water Aspirator 1 0 0 0 0 0
Dishwasher - Commercial 4 0 0 0 0 0
- Domestic 2 0 0 1 2 1 2
Drinking Fountain 1 0 0 0 0 0
Eye Wash 1 0 0 0 0 0
Floor Drain /Sink - 2 inch 2 0 0 0 0 0
- 3 inch 5 0 0 0 0 0
-4 inch 6 0 0 0 0 0
- Car Wash Dr 6 0 0 0 0 0
Garbage Disposal
- Domestic (to 3/4 HP) 16 0 0 0 0 0
- Commercial (to 5 HP) 32 0 0 0 0 0
- Industrial (over 5 HP) 42 0 0 0 0 0
Ice Machine /Refrigerator Drain 1. 0 0 0 0 0
Oil Sep (Gas Station) 6 0. 0 0 0 0
Rec. Vehicle Dump station 16 0 0 0 0 0
Shower - Gang (per head) 1 0 0 0 0 0
- Stall 2 0 0 0 0 0
Sink . Bar /Lavatory 2 0 0 2 4 2 4
- Bradley 5 0 0 0 0 0
- Commercial 3 0 0 1 3 1 3
- Service 3 0 0 0 0 0
Swimming Pool Filter 1 0 0 0 0 0
Washer - Clothes 6 0 0 0 0 0
Water Extractor 6 0 0 0 0 0
Water Closet - Toilet 6 0 0 2 12 2 12
Urinal 6 0 0 0 0 0
Previous EDU Count 0 0
Capped EDU Credit 14 224
TOTALS 0 0 0 0 6 21 6 -203
Current Fixture Value -203 divided by 16 = -12.7 Current EDU 1 EDU = $ 2,600
Previous Fixture Value 0 divided by 16 = 0.0 Previous EDU
Change -203 divided by 16 = -12.7 over (under) $ (33,020.00)
Enter EDU Change Here -12.7
Notes: Credits = 12.7
Authorized Name /Signature: Brian Blalock Date: 11/16/2005
Building Division
Note: The property owner shall retain the ORIGINAL sewer tally record. If credits exist, this document will serve as a voucher
ich must be submitted to the City of Tigard Building Division to redeem credits towards future system development charges.
i:\ Building \Sewer Tally\SewerTallySheet.xls 7/1/05
Building Division
• y ''_ 1I Request for Permit Action or Refund
City of Tigard‘� ED
• �
TO: CITY OF TIGARD •
2 005
Permit System Administrator
13125 SW Hall Blvd., Tigard, OR 97223 N 'TI V SD
Phone: 503.718.2430 Fax: 503.598.1960 GAT ,
B wLD
FROM: ❑ Owner ❑ Applicant Contractor ❑ City Staff
(check one)
(Business or Individual) uttrra eyn (Vt(UC cS i.V ( (
7 - a 3 / f Mailing Address: 4(62. 10E, (1 r _ .
V ® , 1 City/State/Zip: 1.1 MA L A - At , •
/X3 0 Phone No.: r ! Qqa. ' 5(
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (1):
0 CANCEL PERMIT APPLICATION.
REFUND PERMIT FEES.
• REMOVE CONTRACTOR FROM PERMIT (do not cancel_permit).
Permit #: S (/J (2 00S — 0029'
Site Address or Parcel #: l Z Z 8 0 .54.) ,SG //Qe 5 Fax11. £P.
Project Name: OREGON GOnl7UN,7Y GACD If VA-
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Subdivision Name: Lot #:
EXPLANATION: eePLAnd cen 3e(Aje,or �►I'O
•
O
Signature: •L LC Date: //- /g— `J _
Print Name: /MEW/
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Refund Policy
I. The Building Official may authorize the refund of
a) any fee which was erroneously paid or collected
b) not more than 80 percent of the permit fee for issued permits prior to any inspection requests.
c) not more than 80 percent of plan review fee when an application is canceled before any plan review effort has been expended.
2. Refunds will be returned to the original Payer in the same method in which payment was received.
FOR OFFICE USE ONLY
Rte to S s Admin: Date // LgL1'lerr1J Rte to Bld: Admin: Date B
Refund Processed: Date / Z:F OS B A oice Processed: Date B
Permit Canceled: Date f ZB' o S 13 ` ' arcel To: Added: Date B
Receipt #45 Date - i9 05 Method 6 Amount $ ?JI . G�
1:\ Building\Forms\RegPermitAction- Bldg.doc Rev 10/17/05
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pcmnww
NOV 1 7 2005
BY: